Psychosis

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					PSYCHOSIS

   2007
                        Summary
   Common psychiatric emergency may present to health
    services other than mental health team.
   Co-morbidities are common - increase with age
   First episodes best treated by specialist multidisciplinary
    teams delivering psychosocial interventions as well as
    drugs.
   Treatment achieves complete remission without relapse
    in 25%
   Use of low dose well tolerated atypical antipsychotic
    increases compliance and reduces future relapses
                      Terminology
   Psychosis
       disorder of thinking and perception where typically
        patients do not ascribe their symptoms to a mental
        disorder
   Positive symptoms
       Delusions, hallucinations, thought disorder
   Negative symptoms
       A deficit state – what is not there
   Delusion
       False unshakeable belief out of keeping with the
        patients cultural educational and social background
             Terminology
Hallucination
  A sensory perception experienced in the
    absence of a real stimulus
Prodrome
  A definable period before the onset of
    psychotic symptoms during which
    functioning becomes impaired.
                 Frequency
 1 yr prevalence of non organic psychosis is
  4.5/1000 community residents.
 Commonest age of presentation men < 30
  women < 35 and people >60.
 Schizophrenia has a 1 yr prevalence of 3.3/1000
  and life time morbidity of 7.2/1000
 Psychotic symptoms have a 10.1% prevalence in
  non demented community > 85yrs
     Disorders in which psychotic
          symptoms occurs
 Schizophrenia
 Bipolardisorder
 Depression
 Substance misuse particularly
  cannabis
 Dementia
 Parkinson’s disease
     Other causes of psychosis
 Neurological
   Epilepsy
   Head injury
   CVA
   Infection
   Tumours
 Most causes of delirium
              Schizophrenia
 Incidence increased by
   Ethnic origin
   Migration
   Economic inequality in areas of high
    deprivation
                      Diagnosis

   Diagnosis based on clinical findings
   No confirmatory tests
   Investigations might be required to rule out
    organic psychosis.
   Most information gained on first assessment
   Antipsychotic treatment can reduce strength of
    delusion
   Patients learn quickly that disclosing symptoms
    can lead to implications for drugs and liberty
                            History

   Important to gain patients trust by
       Recording presenting complaints first
       Listening empathically
   Open questions
       How have things been for you lately
       Do you think something funny has been going on
       Have you heard unusual noises or voices
       Could someone be behind this
                         History

   Enquire about 3 core mood symptoms
     Mood
     Energy
     Interest   and pleasure
   Psychosis + major alterations in mood
    may indicate bipolar or schizoaffective
    disorders.
         Other aspects of history
   Symptoms in other systems especially
    neurological and endocrine
   Past psychiatric symptoms
   Past medical history and medication
   Family history of mental health and suicide
   Alcohol and substance misuse
   Allergies and adverse drug reactions
        Mental state examination
 Thorough documentation improves accuracy
  now and in later years
 General behaviour
     over arousal and hostility suggestive of positive
      symptoms.
     Irritability suggestive of elevated mood
     Catatonia and negativism rare
     Altered consciousness unusual in non organic
      psychosis
     Intermittent clouding suggests delirium
        Mental state examination
   General behaviour
     Disorganised speech indicates thought
      disorder
     Stilted and difficult conversation occurs with
      negative symptoms
     New words – neologisms best written down
     Random changes in conversation
     Fast or pressured speech suggests mania
       Mental State Examination
   Mood
     Depressed    or elevated
   Affect
     Normal    or flat
 Asses suicidal risk
 Cognitive impairment
     Grossly abnormal indicates learning disability
      or organic disorder
           Differential diagnosis
   Bipolar affective disorder
   Schizoaffective disorder
   Severe depression with psychotic features
   Delusional disorder
   Post traumatic stress disorder
   Obsessive compulsive disorder
   Schizotypal or paranoid personality disorder
   Aspergers
   ADHD
           Collateral history
 Important as family or friends may have
  noted strange behaviour
 May identify a prodrome
 Acute stress causing symptoms
 Gain information about premorbid
  personality
 Are beliefs culturally sanctioned and not
  delusional
        Positive psychotic symptoms
   Paranoid delusion
       Any delusion that refers back to self
   Delusions of thought interference
       Delusions that others can hear read insert or steal
        one’s thoughts
   Passivity phenomena
       Beliefs that others can control your will, limb
        movements, bodily functions or feelings.
   Thought echo
       Hearing own thoughts spoken out loud
        Positive psychotic symptoms
   Third person auditory hallucinations
       Voices speaking about the patient, running
        commentaries – common in non affective psychosis
 Hallucinations without affective content
 Second person auditory hallucinations
       Voices speaking to patient - may give commands
   Thought disorder
       Thought block, over inclusive thinking, difficulties in
        abstract thought – can’t explain proverbs
              Negative symptoms
 Apathy – disinterest blunted affect
 Emotional withdrawal – flat affect
 Odd or incongruous affect
       Smiling when recounting sad events
 Lack of attention to personal hygiene
 Poor rapport
       Reduced verbal and non verbal communication no
        eye contact
   Lack of spontaneity and flow of conversation
      Which treatment setting
 Best treated in least restrictive setting
 70% of first episodes end up in
  hospital
 Older adults, adolescents and post
  partum women have complex needs
  and require admission to specialist
  units.
                 Treatment
   Patients declining treatment need
    assessment under the mental health act
      Danger to self –suicide, unsafe
       behaviour, exploitation by others
      Danger to others – over arousal,
       potential to harm, risk of acting on
       delusion
          Special Groups

Groups   requiring special units
 Older Adults
 Adolescents
 Post- partum women
                  Management
   Listen to patients relatives to catch relapse early
    and identify harmful components of ward
    environment
   Consult with early intervention team
   Identify and change environmental factors that
    perpetuate psychosis
   When new symptoms occur consider drug side
    effects
   Start psychosocial interventions early
   Test for substance misuse
                 Management
   All antipsychotics cause
     Sedation
     Weight  gain
     Impaired glucose tolerance – metabolic
      syndrome insulin resistance increased risk
      cardiovascular events measure waist circ.
     Lower seizure threshold
     ? Increased risk of thromboembolism
      Typical antipsychotic drugs
   Cause more
       Extrapyramidal  sideffects
       Raised prolactin – sexual dysfunctions and
        galactorrhoea
       Anticholinergic sideffects – dry mouth tachycardia
        urinary obstruction
       Antiadrenergic – postural hypotension impotence
           Management

 Psychosocial   with strong evidence
 for benefit
   CBT  reduces impact of symptoms
   Family interventions prevent
    relapse
   Psycho educational interventions
   Supported employment
                Prognosis
 Relapse   at one year
   Antipsychotictreatment but on
   psychosocial intervention
     40% but 62% if in stressful environment
     27% of patients with first psychotic episode
     48%when 5th or more psychotic episode
              Prognosis

 Relapse   at one year
  Placebo treatment no psychosocial
   intervention
   61%  with first psychotic episode
   87% with 5th or more psychotic
    episodes
              Prognosis

 Relapse   at one year
  Antipsychotic treatment with
   psychosocial interventions
   19% with family education
   20% with social skills training
   0% with both interventions
              Prognosis
 Recovery at 15-25 years defined as
 global assessment of function >60

   37.8% with schizophrenia
   54.8% with other psychosis
                  Maintenance
   After recovery
     Single antipsychotic for one year after first
      episode followed by gradual withdrawal in
      asymptomatic patients
     Multiple psychotic episodes require longer
      prophylaxsis
        There are high personal and health service costs
        for relapse so decisions need to be made carefully
                 Risk of Relapse
   Indicators of relapse are
     Residual disability
     Family history of psychosis
     Current substance misuse

				
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